Oral: Must be taken first thing in the morning and on an empty stomach with ≥ 8oz of plain water. Must remain upright for 30mins (alendronate, risedronate) or 60mins (ibandronate)
5 year therapy, may extend to 10 if T \<-2.5 on next DEXA
CI: GFR \<30-35%, achalasia, Schatzki ring
SE: GI, hypocalcemia, osteonecrosis of the jaw
Alendronate (Fosamax)
5mg daily or 35mg weekly PO (prevention)
10mg daily or 70mg weekly PO (treatment)
Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
Approved for treatment of osteoporosis in men, glucocorticoid-induced
Risedronate (Atelvia, Actonel)
35mg weekly or 150mg monthly
Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
Approved for treatment of osteoporosis in men, glucocorticoid-induced
Zoledronic Acid (Reclast, Zometa)
5mg yearly, IV only for treatment, 5mg IV every other year for prevention
Approved for treatment of osteoporosis in men, glucocorticoid-induced
Once a year, improved survival if given within 90 days of hip fracture
May extend to 6 years if very high risk
Efficacious in preventing vertebral and non-vertebral fractures as well as hip fractures
SE: 30% have low-grade fever, myalgia, and arthralgia occurring 1-3 days after 1st administration, usually absent with subsequent infusions.
Ibandronate (Boniva)
150mg once a month
Only efficacious in preventing vertebral fracture
Approved only for treatment of postmenopausal osteoporosis
PTH Analogs
Anabolic: stimulates osteoblasts, only ones available
Reserved for T \<-2.5 and a fracture (severe disease)
Efficacious in preventing vertebral and non-vertebral fractures
Can only be used for 2 years due to cumulative risk of osteosarcoma, use 1 on one off
Must transition to either bisphosphonate or denosumab when discontinued (antiresorptive) within 1 month
No holiday
CI: CDK
SE: Theoretical Increased risk of bone osteosarcoma